0112 Surface Scanning and Macro Electromyography...Surface Scanning and Macro Electromyography...

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Surface Scanning and Macro Electromyography

Policy History

Last Review

05/30/2019

Effective: 01/17/1996

Next

Review: 01/23/2020

Review History

Definitions

Additional Information

Clinical Policy Bulletin

Notes

Number: 0112

Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.

Aetna considers high-density surface electromyography (HD-

sEMG), surface scanning EMG, paraspinal surface EMG, or

macro EMG experimental and investigational as a diagnostic

test for evaluating low back pain or other thoracolumbar

segmental abnormalities such as soft tissue injury,

intervertebral disc disease, nerve root irritation and scoliosis,

and for all other indications because the reliability and validity

of these tests have not been established.

Aetna considers surface EMG devices experimental and

investigational for diagnosis and/or monitoring of

nocturnal bruxism and all other indications because the

reliability and validity of these tests have not been

demonstrated.

Aetna considers the Neurophysiologic Pain Profile (NPP) and

the spine matrix scan (lumbar matrix scan) experimental and

investigational because the reliability and validity of these tests

has not been established.

https://www.aetna.com/


Aetna considers spinoscopy (Spinoscope, Spinex Corp.), a

diagnostic technique that combines surface scanning EMG

with video recordings, experimental and investigational as the

clinical value of this diagnostic technique has not been

validated.

Note: Surface scanning EMG should not be confused with

conventional needle EMG, nor with the use of surface

electrodes in EMG biofeedback techniques, which are

considered medically necessary for appropriate indications.

Also see

CPB 0502 - Nerve Conduction Studies

(../500_599/0502.html)

Background

Surface scanning electromyography (EMG) is different from

the conventional needle EMG. Surface scanning EMG

employs a scanner with self-contained electrodes and/or

surface electrodes that are applied to the skin, and record a

specific muscle or group of muscles' electrical potential. There

have been attempts to use this technology to diagnose back

pain, soft tissue injury, temporomandibular joint dysfunction,

nerve root irritation, and scoliosis.

Paraspinal EMG is a type of surface scanning EMG that has

been used in evaluation of back pain. The rationale for the

use of surface scanning EMG in the evaluation of low back

pain (LBP) appears to be based on the notion that there is a

direct relationship between muscular pain and elevated

myoelectrical behaviors. However, some investigators have

reported no differences in paraspinal EMG levels as a function

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of pain state in patients with LBP, and a review of the literature

indicates that the relationship between increased EMG activity

and the diagnosis/severity of LBP is still highly controversial.

Spine matrix scans (also known as lumbar matrix scans) are

theorized to collect thousands of bioelectrical signals from the

back and reconstruct them into easily interpreted images.

Another test that incorporates surface EMG as a component in

the evaluation of chronic pain is the Neurophysiologic Pain

Profile (NPP).

To date, surface scanning EMG has not been proven to be

effective as a diagnostic tool in the evaluation of LBP and

other thoracolumbar segmental abnormalities. The field of

scanning EMG is only at the beginning of understanding the

characteristics of the surface EMG signal and its relationship

to impairment. Further investigation is needed before this

technology can be used in a clinical setting.

Systematic evidence reviews supporting the use of surface

EMG have suffered from substantial limitations. Mohseni-

Bandpei et al (2000) reported on a literature review of surface

EMG in the diagnosis of LBP. The authors found that

substantial variation in the included studies regarding the

methodology, procedure, type of muscle contraction, sample

size, and the duration, degree and source of the patients'

pain. "However, based on this review, there appears to be

convincing evidence that SEMG is a reliable and valid tool for

differentiating LBP patients from normal people and for

monitoring rehabilitation programmes." A critical assessment

of the review by Mohensi-Bandpei et al by the Centre for

Reviews and Dissemintation (2003) found that "[t]he

information presented does not provide adequate support for

the authors' conclusions." The study by Mohensi-Bandpei et al

was criticized on a number of counts: (i) the methods used to

select the studies were not reported and validity was not

formally assessed; (ii) the methods used to extract the data

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were not described; (iii) the studies were combined by

counting the number of studies classified as having positive

or negative conclusions without assessing the validity of the

original authors' conclusions; (iv) the review contained

insufficient details of the methods used to conduct the

review, and no information on the internal or external

validity of the results; and (v) the review examined whether

the surface EMG levels were different in people with LBP

and "normals", rather than assessing the diagnostic

accuracy of surface EMG in LBP.

A more recent evidence review of surface EMG suffers from

many of these same limitations. Based on a review of the

evidence, Geisser et al (2005) found that some surface EMG

measures had the potential to distinguish between people with

and without LBP. A critical review of the study by Geisser et al

by the Centre for Reviews and Dissemintation stated that "[t]

hese findings should be interpreted with extreme caution given

the limitations in the search and analysis, and the failure to

assess study quality and report review methods." The CRD

found that the literature search by Geisser et al was limited

to 1 database and no attempts were made to identify

unpublished studies. "It was therefore likely that relevant

studies had been missed and the review may be subject to

publication bias." The CRD review also noted that the quality

of the included studies was not assessed, so it was not

possible to assess the validity of the findings. The CRD review

also found that details of the review process were not

reported, "thus it was unclear whether appropriate steps were

taken to minimise bias." The CRD review also found that the

methods used to pool the data "were not reported clearly and

did not seem appropriate for the calculation of summary

sensitivity and specificity, which appeared simply to be an

average value." The CRD review found that, where multiple

comparison groups shared a control group, no adjustment for

statistical dependency was made. The CRD review also found

that the range of reported diagnostic values suggested that

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results were not always consistent among studies and that

pooling may not have been appropriate. "In view of the lack of

reporting of review methods, the lack of a quality assessment

of the included studies, differences between the studies and

concerns about the methods of analysis, the authors'

conclusions may not be reliable."

Surface EMG has also been attempted to diagnose and

monitor nocturnal bruxism. Bruxism (the grinding and

clenching of teeth) causes abnormal wear of the teeth, sounds

associated with bruxism, and jaw muscle discomfort. Portable

EMG units are available for use by patients in the home, and

involve placement of electrodes on the skin over the muscle

being studied (e.g., masseter). Self-monitoring recordings can

be imprecise due to recording problems, inconsistent and

improper electrode placement, and the collection of muscle

activity not associated with occlusal pressure (e.g., oral activity

such as yawning and swallowing). An EMG is not required to

diagnose bruxism as the consequences of this condition can

be observed clinically during a regular dental examination.

Spinoscopy is a testing and analysis procedure that uses a

Spinex Spinoscope® System to evaluate the functional status

of the back. The Spinoscope is a computer-driven multi-

camera video and EMG system that records vertebral

movement and the corresponding muscular activity during

movements of the back. Spinoscopy has been used to track

the coordination of the back and identifies the conditions under

which that coordination breaks down. The value of spinoscopy

evaluation in diagnosing and monitoring patients with back

problems and ultimately improving their outcomes has not

been demonstrated in the published peer-reviewed medical

literature.

Leclaire and colleagues (1996) examined the diagnostic

accuracy of four technologies (namely clinical examination,

spinoscopy, thermography, and tri-axial dynamometry) in

assessing LBP. A total of 41 patients and 46 control subjects

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were assessed by each technology and by 2 clinical

examiners blind to clinical status. Twenty patients were

trained to simulate a healthy back without LBP, and 50 % of

the control subjects were trained to simulate the presence of a

LBP disorder. Each technology was interpreted on 2

occasions by each of 2 readers. Thermography performed

significantly worse than did tri-axial dynamometry, spinoscopy,

and clinical examination. The diagnostic accuracy of the last 3

was similar, and inter-rater comparability did not differ

significantly. Among simulators, the diagnostic accuracy of

spinoscopy and tri-axial dynamometry was significantly higher

than that of clinical examination, although considerable

inaccuracy remained in assessing individual subjects. The

authors concluded that the diagnostic accuracy of

thermography in recent onset LBP does not support its use.

Among those simulating normality or LBP, spinoscopy and tri-

axial dynamometry have greater diagnostic accuracy than

does a single clinical evaluation. However, for an individual,

the inaccuracy that remains limits the use of spinoscopy or tri-

axial dynamometry for diagnosis in recent onset LBP.

Furthermore, in a best-evidence review of diagnostic

procedures for LBP and neck pain (Rubinstein and van Tulder,

2008), spinoscopy was not mentioned as a diagnostic option

for these conditions.

Fuglsang-Frederiksen (2006) evaluated different EMG

methods in the diagnosis of myopathy. These include manual

analysis of individual motor unit potentials and multi-motor unit

potential analysis sampled at weak effort. At high effort, turns-

amplitude analyses such as the cloud analysis and the peak

ratio analysis have a high diagnostic yield. The EMG can

seldom be used to differentiate between different types of

myopathy. In channelopathies and myotonia, exercise testing

and cooling of the muscle are helpful. Macro-EMG, single-

fiber EMG and muscle fiber conduction velocity analysis have

a limited role in myopathy, but provide information about the

changes seen. The authors concluded that analysis of the

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firing rate of motor units, power spectrum analysis, as well as

multi-channel surface EMG may have diagnostic potential in

the future.

Sanger (2008) presented the findings of a pilot study on the

use of a portable surface EMG device for the evaluation of

childhood hypertonia. A total of 7 children aged 5 to 17 years

with hypertonia due to cerebral palsy were each examined by

6 clinicians, both with and without the use of surface EMG.

The use of surface EMG resulted in an increase in inter-rater

agreement as well as an increase in the self-reported

confidence of the clinicians in their assessment. The authors

concluded that these results support the importance of further

testing of surface EMG as an adjunct to the clinical

examination of childhood hypertonia.

The Work Loss Data Institute's clinical guidelines on "Low

back - lumbar & thoracic (acute & chronic)" (2011) and "Neck

and upper back (acute & chronic) (2011) do not recommend

the use of surface EMG.

In a meta-analysis, Perinetti et al (2011) evaluated the

scientific evidence for detectable correlations between the

masticatory system and muscle activity of the other body

districts, especially those mainly responsible for body

posture via the use of surface EMG . A literature survey was

performed using the PubMed database, covering the period

from January 1966 to April 2011, and choosing medical

subject headings. After selection, 5 articles qualified for the

final analysis. One study was judged to be of medium-quality,

the remaining 4 of low-quality. No study included a control

group or follow-up; in only 1 study, subjects with impairment of

the masticatory system were enrolled. In all studies,

detectable correlations between the masticatory systems and

muscle activity of the other body districts, or vice versa, were

found; however, after a re-appraisal of the data provided in

these studies, only weak correlations were found, which

reached biological, but not clinical relevance. With the

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limitations that arise from the poor methodological quality of

the published studies discussed here, the conclusion was that

a correlation between the masticatory system and muscle

activity of the other body districts might be detected through

surface EMG under experimental conditions; however, this

correlation has little clinical relevance. While more

investigations with improved levels of scientific evidence are

needed, the current evidence does not support clinically

relevant correlations between the masticatory system and the

muscle activity of other body districts, including those

responsible for body posture.

Drost et al (2006) stated that high density-surface EMG (HD-

sEMG) is a non-invasive technique to measure electrical

muscle activity with multiple (more than 2) closely spaced

electrodes overlying a restricted area of the skin. Besides

temporal activity, HD-sEMG also allows spatial EMG activity to

be recorded, thus expanding the possibilities to detect new

muscle characteristics. Especially muscle fiber conduction

velocity (MFCV) measurements and the evaluation of single

motor unit (MU) characteristics come into view. These

investigators evaluated the clinical applications of HD-sEMG.

Although beyond the scope of the present review, the search

yielded a large number of "non-clinical" papers demonstrating

that a considerable amount of work has been done and that

significant technical progress has been made concerning the

feasibility and optimization of HD-sEMG techniques. A total of

29 clinical studies and 4 reviews of clinical applications of HD-

sEMG were considered. The clinical studies concerned

muscle fatigue, motor neuron diseases (MND), neuropathies,

myopathies (mainly in patients with channelopathies),

spontaneous muscle activity and MU firing rates. In principle,

HD-sEMG allows pathological changes at the MU level to be

detected, especially changes in neurogenic disorders and

channelopathies. Furthermore, the authors discussed several

bioengineering aspects and future clinical applications of the

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technique and provided recommendations for further

development and implementation of HD-sEMG as a clinical

diagnostic tool.

Zhou et al (2012) noted that HD-sEMG has recently emerged

as a potentially useful tool in the evaluation of amyotrophic

lateral sclerosis (ALS). These researchers addressed a

practical constraint that arises when applying HD-sEMG for

supporting the diagnosis of ALS; specifically, how long the

sEMG should be recorded before one can be confident that

fasciculation potentials (FPs) are absent in a muscle being

tested. High density-sEMG recordings of 29 muscles from 11

ALS patients were analyzed. These investigators used the

distribution of intervals between FPs, and estimated the

observation duration needed to record from 1 to 5 FPs with a

probability approaching unity. Such an approach was

previously tested by Mills with a concentric needle electrode.

These researchers found that the duration of recording was up

to 70 s in order to record a single FP with a probability

approaching unity. Increasing recording time to 2 minutes, the

probability of recording 5 FPs approached approximately

0.95. The authors concluded that HD-SEMG appears to be a

suitable method for capturing FPs comparable to intra-

muscular needle EMG.

Kleine et al (2012) compared the prevalence of FPs with

F-responses between patients with ALS and patients with

benign fasciculations. In 7 patients with ALS and 7 patients

with benign fasciculations, HD-s EMG was recorded for 15

mins from the gastrocnemius muscle. Template matching was

used to search for pairs of FPs with a repetition within 10 to

110 ms. Inter-spike interval (ISI) histograms were constructed

from 282 pairs of benign fasciculations and from 337 FP pairs

in ALS. Peaks attributable to F-waves were found at latencies

of 32 ms (benign) and 35 ms (ALS); 5 patients with benign

fasciculations and 4 patients with ALS had FPs with F-waves.

The authors concluded that F-waves of FPs occur in both

conditions; therefore they are not diagnostically helpful. They

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noted that F-waves confirm the distal origin of FPs for an

individual axon. The occurrence of these FPs in a benign

condition suggests that the generation of ectopic discharges in

the distal axons is not specific to progressive

neurodegeneration.

Rojas-Martinez et al (2012) sEMG signal has been widely

used in different applications in kinesiology and rehabilitation

as well as in the control of human-machine interfaces. In

general, the signals are recorded with bipolar electrodes

located in different muscles. However, such configuration may

disregard some aspects of the spatial distribution of the

potentials like location of innervation zones and the

manifestation of inhomogineties in the control of the muscular

fibers. On the other hand, the spatial distribution of motor unit

action potentials (MUAPs) has recently been assessed with

activation maps obtained from HD-EMG signals, these lasts

recorded with arrays of closely spaced electrodes. These

researchers analyzed patterns in the activation maps,

associating them with 4 movement directions at the elbow joint

and with different strengths of those tasks. Although the

activation pattern can be assessed with bipolar electrodes,

HD-EMG maps could enable the extraction of features that

depend on the spatial distribution of the potentials and on the

load-sharing between muscles, in order to have a better

differentiation between tasks and effort levels. An

experimental protocol consisting of isometric contractions at 3

levels of effort during flexion, extension, supination and

pronation at the elbow joint was designed and HD-EMG

signals were recorded with 2D electrode arrays on different

upper-limb muscles. Techniques for the identification and

interpolation of artifacts were explained, as well as a method

for the segmentation of the activation areas. In addition,

variables related to the intensity and spatial distribution of the

maps, were obtained, as well as variables associated to signal

power of traditional single bipolar recordings. Finally,

statistical tests were applied in order to assess differences

between information extracted from single bipolar signals or

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from HD-EMG maps and to analyze differences due to type of

task and effort level. Significant differences were observed

between EMG signal power obtained from single bipolar

configuration and HD-EMG and better results regarding the

identification of tasks and effort levels were obtained with the

latter. Additionally, average maps for a population of 12

subjects were obtained and differences in the co-activation

pattern of muscles were found not only from variables related

to the intensity of the maps but also to their spatial

distribution. The authors concluded that intensity and spatial

distribution of HD-EMG maps could be useful in applications

where the identification of movement intention and its strength

is needed, for example in robotic-aided therapies or for

devices like powered- prostheses or orthoses. Moreover, they

stated that additional data transformations or other features

are needed improve the performance of tasks identification.

The clinical effectiveness of HD-sEMG has not been

established; well-designed studies are needed to ascertain the

clinical utility of HD-sEMG.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description

CPT codes not covered for indications listed in the CPB:

Neurophysiologic Pain Profile (NPP), Spine Matrix Scan -hyphen no specific code:

96002 Dynamic surface electromyography, during

walking or other functional activities, 1-12

muscles

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96004 Review and interpretation by physician or other

qualified health care professional of

comprehensive computer-based motion

analysis, dynamic plantar pressure

measurements, dynamic surface

electromyography during walking or other

functional activities, and dynamic fine wire

electromyography, with written report

HCPCS codes not covered for indications listed in the CPB:

S3900 Surface electromyography (EMG)

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):

F45.8 Other somatoform disorders

G54.0 -

G54.9

Nerve root and plexus disorders

G57.0 -

G57.93

Mononeuropathies

M41.0 -

M41.87,

M41.9

Kyphoscoliosis and scoliosis

M50.00 -

M51.9

Intervertebral disc disorders

M53.0 -

M53.9

Other and unspecified disorders of back

M60.9 Myositis, unspecified

M62.830

-

M62.838

Muscle sp asm

M62.9 -

M63.89

Disorders of muscle, ligament, and fascia,

unspecified or in diseases classified elsewhere

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M79.10 -

M79.18

Myalgia

Q67.5,

Q76.2 -

Q76.3

Q76.425

Q76.429

Certain congenital musculoskeletal anomalies

of spine

S23.3xx+,

S23.8xx+

Sprains and strains of other and unspecified

parts of thorax

S30.0xx+ Contusion of low back and pelvis

S33.5xx Sprain of ligaments of lumbar spine

S39.002+,

S39.012+

S39.092+,

S39.82x+

Other specified injuries of lower back

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34. Kankaanpaa M, Taimela S, Webber CL Jr, et al. Lumbar

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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

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responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is

subject to change.

Copyright © 2001-2020 Aetna Inc.

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AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment toAetna Clinical Policy Bulletin Number: 0112 Surface

Scanning and Macro Electromyography

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania annual 08/01/2020

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http://www.aetnabetterhealth.com/pennsylvania

Surface Scanning and Macro Electromyography CPT Codes / HCPCS Codes / ICD-10 Codes ReferencesAmendment to Aetna Clinical Policy Bulletin Number: 0112 Surface Scanning and Macro Electromyography

0112 Surface Scanning and Macro Electromyography...Surface Scanning and Macro Electromyography...

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